Chapter 33: Pancreas Flashcards Preview

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Flashcards in Chapter 33: Pancreas Deck (152):
1

Rests on aorta, behind SMV

Uncinate process

2

Lays behind neck of pancreas

SMV and SMA

3

Forms behind the neck (SMV and splenic vein)

Portal vein

4

Blood supply to head of pancreas

Superior (off GDA) and inferior (off SMA), pancreaticoduoenal arteries (anterior and posterior branches for each)

5

Blood supply to body of pancreas

great, inferior, and caudal pancreatic arteries (all off splenic artery)

6

Blood supply to tail of pancreas

Splenic, gastroepiploic and dorsal pancreatic arteries

7

Venous drainage of the pancreas

Portal system

8

Lymphatics for pancreas

Celiac and SMA nodes

9

Pancreas: cells secrete HCO3- solution (have carbonic anhydrase)

Ductal cells

10

Pancreas: cells secrete digestive enzymes

Acinar cells

11

Exocrine function of the pancreas

Amylase, lipase, trypsinogen, chymotrypsinogen, carboxypeptidase, HCO3-

12

Only pancreatic enzyme secreted in active form; hydrolyzes alpha 1-4 linkages of glucose chains

Amylase

13

Endocrine function of the pancreas:
- Alpha
- Beta
- Delta
- PP or F cells
- Islet cells

- Alpha: glucagon
- Beta: (center of islets): insulin
- Delta: somatostatin
- PP or F cells: pancreatic polypeptide
- Islet cells: also produce VIP, serotonin

14

Endocrine: receive majority of blood supply related to size

Islets cells
- after islets, blood goes to acinar cells

15

Released by the duodenum, activates trypsinogen to trypsin

Enterokinase

16

After being activated by enterokinase, Activates pancreatic enzymes, including trypsinogen

Trypsin

17

Hormonal control of pancreatic excretion

Secretin, CCK, Acetylcholine, somatostatin, glucagon, CCK and secretin

18

Increases HCO3- mostly

Secretin

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Increases pancreatic enzymes mostly

CCK

20

Increases HCO- and enzymes

Acetylcholine

21

Decreases exocrine function

Somatostatin and glucagons

22

Mostly released by cells in the duodenum

CCK and secretin

23

Connected to duct of Wirsung; migrates posteriorly, to the right, and clockwise to fuse with the dorsal bud
- Forms uncinate and inferior portion of the head

Ventral pancreatic bud

24

Body, tail, and superior aspect of the pancreatic head; has duct of Santorini

Dorsal pancreatic bud

25

Major pancreatic duct that merges with CBD before entering duodenum

Duct of Wirsung

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Small accessory pancreatic duct that drains directly into duodenum

Duct of Santorini

27

2nd portion of duodenum trapped in pancreatic band; can see double bubble on abdominal XR; get duodenal obstruction (N/V, abdominal pain)

Annular pancreas

28

What is annular pancreas associated with?

Down syndrome; forms the ventral pancreatic bud from failure of clockwise rotation

29

Tx: annular pancreas

Duodenojejunostomy and duodenoduodenostomy; possible sphincteroplasty
- pancreas not resected

30

Failed fusion of the pancreatic ducts; can result in pancreatitis from duct of Santorini (accessory duct) stenosis
- Most are asymptomatic; some get pancreatitis

Pancreas divisum

31

Dx: pancreas divisum

ERCP - minor papilla will show long and large duct of Santorini; major papilla will show short duct of Wirsung

32

Tx: pancreas divisum

ERCP with sphincteroplasty; open sphincteroplasty if that fails

33

- Most commonly found in duodenum
- usually asymptomatic
- surgical resection if symptomatic

heterotopic pancreas

34

Acute pancreatitis: Most common etiologies in the US

Gallstones and ETOG

35

Etiologies of acute pancreatitis

Gallstones, ETOH, ERCP trauma, HLD, Hyper-Ca, viral infection, medications (azathioprine, furosemide, steroids, cimetidine)

36

How do gallstones cause acute pancreatitis?

Can obstruct the ampulla of Vater, causing impaired extrusion of zymogen granules and activation of degradation enzymes -> leads to pancreatic auto-digestion

37

How does alcohol cause acute pancreatitis?

Can cause auto-activation of the pancreatic enzymes while still in the pancreas

38

Symptoms: abdominal pain radiating to the back, nausea, vomiting, anorexia
- can also get jaundice, left pleural effusion, ascites or sentinel loop (dilated small bowel near the pancreas as a result of the inflammation)

Acute pancreatitis

39

Mortality rate of acute pancreatitis

Mortality rate 10%; hemorrhagic pancreatitis mortality 50%

40

What do you need to worry about in pancreatitis without an obvious cause?

Need to worry about malignancy

41

Ranson's criteria on admission

Age > 55
WBC > 16
Glucose > 200
AST > 250
LDH > 350

42

Ranson's criteria after 48 hours

Hct decrease 10%
BUN increase of 5
Ca 4
Fluid sequestration > 6L

43

What is a patient has 8 components of the Ranson's criteria?

Mortality rate near 100%

44

Labs: acute pancreatitis

Increased amylase, lipase, and WBCs

45

Ultrasound: acute pancreatitis

Needed to check for gallstones and possible CBD dilatation

46

Abdominal CT: acute pancreatitis

To check for complications (necrotic pancreas will not uptake contrast)

47

Tx: acute pancreatitis

NPO, aggressive fluid resuscitation
- ERCP (gallstone pancreatitis and retained CBD stones)
- Antibiotics (stones, severe pancreatitis, failure to improve, or suspected infection)
- TPN (recovery period)
- Cholecystectomy (gall stones)
- No morphine

48

When is ERCP needed in acute pancreatitis?

Gallstone pancreatitis and retained CBD stones -> perform sphincterotomy and stone extraction

49

When are antibiotics needed for acute pancreatitis?

Stones, severe pancreatitis, failure to improve, or suspected infection

50

What is the role of cholecystectomy with acute pancreatitis?

Patients with gallstone pancreatitis should undergo cholecystectomy when recovered from pancreatitis (same hospital admission)

51

Why is morphine avoided in acute pancreatitis?

Should be avoided as it can contract the sphincter of Oddi and worsen attack

52

Sign: flank ecchymosis

Grey Turner sign (bleeding)

53

Sign: periumbilical ecchymosis

Cullen's sign (bleeding)

54

Sign: inguinal ecchymosis

Fox's sign (bleeding)

55

What are three physical exam signs of bleeding?

- Grey turner (flank)
- Cullen's (periumbilical)
- Fox's (inguinal)

56

Rate of pancreatic necrosis

15% get pancreatic necrosis; leave sterile necrosis alone

57

Management: infected pancreatic necrosis

- May need to sample necrotic pancreatic fluid with CT-guided aspiration to get diagnosis
- Surgical debridement

58

Fever, positive blood cultures in acute pancreatitis

Infected necrosis of pancreas

59

Tx: pancreatic abscess

Need surgical debridement

60

Is CT-guided drainage of infected pancreatic necrosis or pancreatic abscess effective?

Generally not effective

61

Gas in necrotic pancreas..

Infected necrosis or abscess (need open debridement)

62

Leading cause of death with pancreatitis

Infection (usually GNRs)

63

When is surgery indicated in pancreatitis?

Only for infected pancreatitis or pancreatic abscess

64

Most important risk factor for necrotizing pancreatitis

Obesity

65

Pancreatitis: complication related to phospholipases

-ARDS
-Pancreatic fat necrosis

66

Pancreatitis: complication related to proteases

Coagulopathy

67

What is related to mild increases in amylase and lipase?

Can be seen with cholecystitis, perforated ulcer, sialoadenitis, small bowel obstruction, and intestinal infarction

68

What is associated with chronic pancreatitis?

Pancreatic pseudocysts

69

Cysts NOT associated with pancreatitis..

Need to r/o CA (eg, mucinous cystadenocarcinoma)

70

Symptoms: pain, fever, weight loss, bowel obstruction from compression

Pancreatic pseudocysts

71

Where do pancreatic pseudocysts often occur?

The head of the pancreas; is a non-epitheliazed sac

72

TX: pancreatic pseudocysts

Most resolve spontaneously (especially if

73

When is surgery indicated in pancreatic pseudocysts?

Continued symptoms (tx: cystogastrostomy, open or percutaneous) or pseudocysts that are growing (tx: resection r/o CA)

74

Complications of pancreatic pseudocysts

Infection of cyst, portal or splenic vein thrombosis

75

Management: incidental cysts not associated with pancreatitis

Should be resected (worry about intraductal papillary-mucinous neoplasms (IPMNs) or mutinous cystuadenocarcinoma) unless the cyst is purely serous and non-complex

76

Management of non-complex , purely serous cyst adenomas

Have an extremely low malignancy risk (

77

- most close spontaneously (especially if low output

Pancreatic fistulas

78

Pancreatic fistulas: tx for failure to resolve with medical management

Can try ERCP, sphincterotomy and pancreatic stent placement (fistula will usually close, then remove stent)

79

What causes pancreatitis-associated pleural effusion (or ascites)?

Caused by retroperitoneal leakage of pancreatic fluid from the pancreatic duct or a pseudocyst (is not a pancreatic-pleural fistula); majority close on their own

80

Tx: pancreatitis-associated pleural effusion (or ascites)

Thoracentesis (or paracentesis) followed by conservative tx (NPO, TPN, and octreotide - follow pancreatic fistula pathway above)
- amylase will be elevated in the fluid

81

Pathophysiology of chronic pancreatitis

Corresponds to irreversible parenchymal fibrosis

82

MCC chronic pancreatitis

1) ETOH 2) Idiopathic

83

Pain most common problem, anorexia, weight loss, malabsorption, steatorrhea, recurrent acute pancreatitis

Chronic pancreatitis

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Endocrine / exocrine chronic pancreatitis

- Endocrine function: usually preserved (Islet cell preserved)
- Exocrine function: decreased

85

Nutritional deficiency in chronic pancreatitis

Can cause malabsorption of fat-soluble vitamins
- Tx: pancrelipase

86

Dx: chronic pancreatitis

- Abdominal CT: shrunken pancreas with calcifications
- US: pancreatic ducts > 4mm, cysts and atrophy
- ERCP: very sensitive

87

How does advanced chronic pancreatitis affect pancreatic duct?

Advanced disease - chain of Lakes - alternating segments of dilation and stenosis in pancreatic ducts

88

Tx: chronic pancreatitis

Supportive, including pain control and nutritional support (pancrelipase)

89

Surgical indications: chronic pancreatitis

Pain that interferes with quality of life, nutrition abnormalities, addiction to narcotics, failure to rule out CA, biliary obstruction

90

Surgical options

Puestow procedure, Distal pancreatic resection, Whipple, Beger-Frey, Bilateral thoracoscopic splanchnicectomy or celiac glanglionectomy

91

Chronic pancreatitis: Puestow procedure

Pancreaticojejunostomy, for enlarge ducts > 8mm (most patients improve) -> open along main pancreatic duct and drain into jejunum

92

Chronic pancreatitis: distal pancreatic resection

For normal or small ducts and only distal portion of the gland is affected

93

Chronic pancreatitis: whipple

For normal or small ducts with isolated pancreatic head disease

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Chronic pancreatitis: beger-frey

Duodenal preserving head ("core-out") - for normal or small ducts with isolated pancreatic head enlargement

95

Chronic pancreatitis: techniques for pain control

Bilateral thoracoscopic splanchnicectomy or celiac ganglionectomy

96

Chronic pancreatitis: causes CBD dilation

Common bile duct stricture
- Tx: hepaticojejunostomy or choledochojejunostomy for pain, jaundice, progressive cirrhosis, or cholangitis (make sure the stricture is not pancreatic CA)

97

MCC splenic vein thrombosis

Chronic pancreatitis

98

Tx: splenic vein thrombosis

Can get bleeding from isolated gastric varies that form as collaterals
- Tx: splenectomy for isolated bleeding gastric varices

99

What causes pancreatic insufficiency?

Usually the result of long-standing pancreatitis or occurs after total pancreatectomy (over 90% of the function must be lost)
- Generally refers to exocrine function

100

Symptoms: pancreatic insufficiency

Malabsorption and steatorrhea

101

Dx: pancreatic insufficiency

Fecal fat testing

102

Tx: pancreatic insufficiency

High-carbohydrate, high-protein, low-fat diet; pancreatic enzymes (pancrease)

103

Jaundice workup

Ultrasound first
- positive CBD stones, no mass -> ERCP (allows extraction of stones)
- No CBD stones, no mass-> MRCP
- Positive mass-> MRCP

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- male predominance; usually 6th-7th decades of life
- symptoms: weight loss (MC symptom), jaundice, pain

pancreatic adenocarcinoma

105

5 year survival rate with resection of pancreatic adenocarcinoma

20%

106

#1 risk factor for pancreatic adenocarcinoma

tobacco

107

Serum marker / mutation for pancreatic CA

- CA19-9: serum marker
- 95% have p16 mutation (tumor suppressor, binds cyclin complexes)

108

How does pancreatic adenocarcinoma spread?

Lymphatic spread first

109

Where are pancreatic adenocarcinomas found?

- 70% head
- 90% ductal adenocarcinoma

110

How does pancreatic adenoCA in the head usually present?

50% invade portal vein, SMV, or retroperitoneum at time of diagnosis (unresectable disease)

111

What indicates unresectable disease in pancreatic adenoma?

Metastases to peritoneum, omentum or liver. Metastases to celiac or SMA nodal system (nodal systems outside area of resection)

112

What offers the best chance of cure in pancreatic adenoCA?

Most cures in patients with pancreatic head disease

113

What offers a more favorable prognosis in ductal adenocarcinoma?

Papillary or mucinous cyst-adenocarcinoma

114

Labs: pancreatic adenocarcinoma

Increased conjugated bilirubin and alkaline phosphatase

115

Do patients with resectable pancreatic adenocarcinoma need a biopsy?

Do not need a biopsy because you are taking it out regardless. if the patient appears to have metastatic disease, a biopsy is warranted to direct therapy

116

Good at differentiating dilated ducts secondary to chronic pancreatitis vs CA

MRCP

117

Signs of CA on MRCP

Duct with regular narrowing, displacement, destruction; can also detect vessel involvement

118

What will abdominal CT show in pancreatic adenocarcinoma?

May show the lesion and double-duct sign for pancreatic hear tumors (dilation of both the pancreatic duct and CBD)

119

Mananagement unresectable pancreatic adenoCA

Consider palliation with biliary stents or hepaticojejunostomy (for biliary obstruction), gastrojejunostomy (for duodenal obstruction), and celiac plexus ablation (for pain)

120

Complications from Whipple

Delayed gastric emptying (#1 - tx: metoclopramide), fistula (tx; conservative therapy), leak (place drains and tx like a fistula), marginal ulceration (tx: ppi)

121

#1 complication after Whipple

Delayed gastric emptying

122

Management: bleeding after Whipple or other pancreatic surgery

Go to angio for embolization (the tissue planes are very friable early after surgery, and bleeding is hard to control operatively)

123

Postop management pancreatic adenoCa

Chemo-XRT usual post op (gemcitabine)

124

Prognosis for non-metastatic disease pancreatic adeno ca

Prognosis for non-metastatic disease related to nodal invasion and ability to get a clear margin

125

Represent 1/3 of pancreatic endocrine neoplasms
- tend to have a more indolent and protracted course compared with pancreatic adenoCA

Non-functional endocrine tumors

126

Malignancy potential of non-functional endocrine tumors

90% of the nonfunctional tumors are malignant

127

Surgical management: non-functional endocrine tumors

Resect these lesions: metastatic disease precludes resection

128

Chemotherapy: non-functional endocrine tumors

5FU and streptozocin may be effective

129

MC site of metastases in non-functional endocrine tumors

Liver

130

Represent 2/3 of pancreatic endocrine neoplasms
- all tumors respond to debulking

Functional endocrine pancreatic tumors

131

Treatment effective for insulinoma, glucagonoma, gastrinoma, VIPoma

Octreotide

132

Functional endocrine pancreatic tumors: most common in pancreatic head

Gastrinoma, somatostatinoma

133

Metastases of functional endocrine pancreatic tumors

Liver metastatic spread - 1st for all

134

- MC islet cell tumor of the pancreas
- Whipple's triad
- 90% are benign and evenly distributed throughout pancreas

Insulinoma

135

- Fasting hypoglycemia (

Whipple's triad

136

Dx: insulinoma

-Insulin to glucose ratio > 0.4 after fasting
- Increased C peptide and proinsulin (if not elevated, suspect Munchausen's syndrome)

137

Tx: insulinoma

Enucleate if 2 cm
- For metastatic disease: 5-FU and streptozocin; octreotide

138

- Most common pancreatic islet cell tumor in MEN-1 patients
- 50% malignant and 50% multiple
- 75% spontaneous and 25% MEN-1

Gastrinoma (Zollinger-Ellison Syndrome (ZES))

139

Where are most gastrinomas found?

Gastrinoma triangle: common bile duct, neck of pancreas, third portion of the duodenum

140

Symptoms: refractory or complicated ulcer disease and diarrhea (improved with PPI)
- Serum gastrin usually > 200; 1,000s is diagnostic

Gastrinoma (ZES)

141

Secretin stimulation test in gastrinoma

- ZES: increase gastrin (>200)
- Normal: decrease gastrin

142

Treatment: gastrinoma

Enucleation if 2 cm
- Malignant disease: excise suspicious nodes
- Can't find it: perform duodenostomy and look inside duodenum for tumor (15% of microgastrinomas there)
- Duodenal tumor: resection with primary closure, may need Whipple
- Debulking, can improve symptoms
- Octreotide scan

143

Single best test for localizing tumor

Octreotide scan

144

- Symptoms: diabetes, stomatitis, dermatitis (rash - necrolytic migratory erythema), weight loss
- Diagnosis: fasting glucagon level
- Most malignant; most in distal pancreas

Glucagonoma

145

What can treat skin rash in glucagonoma?

Zinc, amino acids, or fatty acids may treat skin rash

146

Verner-Morrison syndrome

VIPoma

147

Symptoms: watery diarrhea, hypokalemia (diarrhea), and achlorhydria (WDGA)

VIPoma (Verner-Morrison syndrome)

148

Dx: VIPoma

Exclude other causes of diarrhea; increased VIP levels

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Characteristics of VIPoma

- Most malignant
- Most in distal pancreas
- 10% extrapancreatic (retroperitoneal, thorax)

150

- very rare
- symptoms: diabetes, gallstones, steatorrhea, hypochlorhydria
- most malignant, most in head of pancreas

Somatostatinoma

151

Dx: somatostatinoma

fasting somatostatin level

152

Tx: somatostatinoma

Perform cholecystectomy with resection